A client with a possible vancomycin-resistant enterococci (VRE) infection is admitted with purulent drainage from an abdominal surgical incision.
What nursing interventions should be included in the plan of care? Select all that apply.

Send wound drainage for culture and sensitivity.

Explain the purpose of a low bacteria diet.

Use standard precautions and wear a mask.

Institute contact precautions for staff and visitors.

Monitor the client’s white blood cell count.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale

Sending wound drainage for culture and sensitivity is a key step in diagnosing and treating VRE. This can help determine the most effective antibiotic treatment20.

Choice B rationale

There is no specific “low bacteria diet” recommended for VRE infections20.

Choice C rationale

Standard precautions, including wearing a mask, are important for preventing the spread of VRE1617181920.

Choice D rationale

Contact precautions, such as wearing gloves and gowns, are recommended for staff and visitors to prevent the spread of VRE1617181920.

Choice E rationale

Monitoring the client’s white blood cell count can help assess the body’s response to the infection and the effectiveness of treatment20.

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Correct Answer is A

Explanation

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.

Choice B rationale

Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.

Choice C rationale

Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.

Choice D rationale

Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.

A. Altered taste sensation. B. Fatigue. C. Pain during eating. D. Nausea.

Correct Answer is C

Explanation

Choice A rationale

While altered taste sensation can occur with radiation treatment, it’s not the most likely reason for an imbalance in nutritional intake in this scenario.

Choice B rationale

Fatigue can be a side effect of radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.

Choice C rationale

Pain during eating is the most likely cause of imbalanced nutritional intake in this scenario. The patient’s laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the patient from eating, leading to decreased nutritional intake.

Choice D rationale

Nausea can occur with radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.

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A client with a possible vancomycin-resistant enterococci (VRE) infection is admitted with purulent drainage from an abdominal surgical incision.What nursing interventions should be included in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is A

Explanation

A patient undergoing radiation treatment for laryngeal cancer has developed xerostomia and mucositis, leading to an imbalance in nutritional intake.What is the most likely reason for this issue?

Correct Answer is C

Explanation

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A client with a possible vancomycin-resistant enterococci (VRE) infection is admitted with purulent drainage from an abdominal surgical incision.
What nursing interventions should be included in the plan of care? Select all that apply.